APPLICATION FOR EMPLOYMENT

V1.03 2015

Please note that this application takes approximately 10 minutes to complete and information will not be saved until the form is submitted. Please gather your pertinent documents before beginning the application process.

Today's Date (mm-dd-yyyy) *

Chapter/Location *

Position Title

[OFFICE USE ONLY - DO NOT TYPE IN BOX]

Are you applying for? *

If other, please explain here:

How did you learn about this position? *

If other, please explain here:

PERSONAL

First Name *

Last Name *

E-mail address: *

Street Address *

Street Address 2

City *

State *

Zip Code *

Home Phone (999) 999-9999

Mobile Phone (999) 999-9999

Date of Availability (MM-DD-YYYY) *

Are you legally authorized to work for any employer in the U.S.? *

Will you now or in the future require sponsorship? *

Are you willing to work evenings/weekends if asked? *

If hired, would you have a reliable means of transportation to and from work? *

Have you ever applied for or been employed by LLS? If so, which office? *

No

YesYes

Can you perform the essential elements of this job for which

you are applying with or without reasonable accommodation?

*

If not, which accommodations do you require?

You will be asked to submit to a criminal background check upon offer.

EDUCATION

HIGH SCHOOL: Name of School *

Did you graduate? *

Yes

No

COLLEGE: Name of School

Did you graduate?

Yes

No

Degree Received

GRADUATE SCHOOL: Name of School

Did you graduate?

Yes

No

Degree Received

OTHER: Name of Institution

Did you graduate?

Yes

No

Degree Received

COMPUTER PROFICIENCIES

Computer Proficiency *

MAC

PC

Outlook

Word

Excel

Powerpoint

Web Browsing

Social Network Sites

EMPLOYMENT HISTORY

Start with your current or most recent employer. You may exclude names of organizations that indicate race, color, religion, gender, national origin, disabilities or other protected classes.

Job Title *

Current/Most Recent Employer *

Is it okay to contact your supervisor

Yes

From (MM-DD-YYYY) *

To (MM-DD-YYYY)

Name of Supervisor

Salary

Phone (999) 999-9999

Reason for Leaving *

Job Title

Current/Most Recent Employer

Is it okay to contact your supervisor

Yes

From (MM-DD-YYYY)

To (MM-DD-YYYY)

Name of Supervisor

Salary

Phone (999) 999-9999

Reason for Leaving

Job Title

Current/Most Recent Employer

Is it okay to contact your supervisor

Yes

From (MM-DD-YYYY)

To (MM-DD-YYYY)

Name of Supervisor

Salary

Phone (999) 999-9999

Reason for Leaving

Please attach cover letter (PDF or Word) *

Please attach resume (PDF or Word) *

OTHER

Describe any special training, skills, professional affiliations or civic activities you have had relating to the position or type of work you are seeking. You may exclude the name of an organization which may indicate race, color, religion, gender, national origin, handicaps or other protected classes.

0/99999 characters

Please list three persons not related to you who have knowledge of your work performance within the last three years.

Name

Relationship

Phone (999) 999-9999

E-Mail Address

Name

Relationship

Phone (999) 999-9999

E-Mail Address

Name

Relationship

Phone (999) 999-9999

E-Mail Address

AT-WILL EMPLOYMENT

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and The Leukemia & Lymphoma Society. In addition, I understand and agree that if I am employed, my employment is at-will, and may be terminated at any time, with or without prior notice, at the option of either myself or The Leukemia & Lymphoma Society, and that no promises or representations contrary to the foregoing are binding on The Leukemia & Lymphoma Society.

PRE-EMPLOYMENT STATEMENTS

Please read carefully and check the box below stating that you have read and agree with these statements.

I understand and agree that:

1. The information that I have provided on this application (and resume) is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interview, can be justification of refusal of employment, withdraw of any offer of employment, or, if employed, termination from LLS's employ.

2. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and The Leukemia & Lymphoma Society. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or The Leukemia & Lymphoma Society, and that no promises or representations contrary to the foregoing are binding on The Leukemia & Lymphoma Society.

3. Any offer of employment I may receive from LLS is contingent upon my successful completion of the organization's total preemployment screening process, including the organization's receiving references that it considers satisfactory.

4. I authorize and request that all of my former employers furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment at LLS.

5. I understand that any offer of employment is also contingent upon my ability to provide the documentation required by the Immigration Reform and Control Act of 1986 to substantiate that I am legally authorized to work in the United States.

6. I release to LLS the results of any assessment instruments that I may take as part of the selection process.

I have read, understand and agree with the preceding statement

*

DIVERSITY STUDY

Please complete the following survey to help us comply with record-keeping, reporting and other legal requirements.

Important: Please read about voluntary affirmative action self-identificationWe invite all applicants to identify themselves in accordance with federal regulations for affirmative action purposes. If you wish to be identified, please check any of the following areas below that apply. This information is requested on a voluntary basis to assist in LLS's compliance with reporting obligations under Federal Equal Employment Opportunity laws and regulations and LLS's affirmative action efforts. This information will not be used in consideration for your employment and refusal to provide the information will not impact your application. Any information you provide will be recorded and maintained in a confidential file, separate from all other records.

Ethnicity

Race

Gender

Military Service

Vietnam Era Veterans and Other Veterans

Recently Separated Veteran

Armed Forces Service Medal Veteran

PROFESSIONAL LICENSE INFORMATION

Professional License: Type:

Issued by the State of:

Date Issued: (MM-DD-YYYY)

Number:

Professional License: Type:

Issued by the State of:

Date Issued: (MM-DD-YYYY)

Number:

Professional License: Type:

Issued by the State of:

Date Issued: (MM-DD-YYYY)

Number:

ELECTRONIC SIGNATURE

The Leukemia & Lymphoma SocietyCALIFORNIA ACKNOWLEDGEMENT

DISCLOSURE OF EMPLOYER'S INTENTION TO OBTAINCONSUMER REPORT FOR EMPLOYMENT PURPOSES(to be Completed by California Applicants)

The Leukemia & Lymphoma Society ("The Leukemia & Lymphoma Society") may obtain a consumer report on you for employment purposes from LexisNexis Risk & Information Analytics Group, 1000 Alderman Drive, Alpharetta, GA 30005, Telephone: (800) 888-5773. Such report may be obtained in connection with your hiring and/or current employment and additional consumer reports may be obtained in connection with your promotion, reassignment, or retention as an employee. The Leukemia & Lymphoma Society may obtain written, oral, or other communication of information bearing on your character, general reputation, personal characteristics, trustworthiness, creditworthiness, credit standing, credit capacity, or mode of living, from any person or agency which assembles or evaluates individual credit information or other information on individuals for the purposes of furnishing that information to third parties.The Leukemia & Lymphoma Society may also obtain "investigative consumer reports" that may include some or all of the information listed above obtained from public sources, as well as personal interviews with sources such as your neighbors, friends, fellow employees, or associates. You have a right to request disclosure of the nature and scope of such investigative consumer reports.

Before The Leukemia & Lymphoma Society takes any adverse action based in whole or in part on any information contained in a consumer report, it will provide you with a copy of the report, along with information necessary to contact the consumer reporting agency and a summary of your rights under the Fair Credit Reporting Act.

You should understand that the information collected may relate, but may not necessarily be limited, to:

• Past employment history verification

• Military records

• Education history verification

• Verification of licenses and certifications

• Social security verification

• Your creditworthiness or similar characteristics as set forth in a credit history

• Drug test results

• Any criminal or civil legal records

• All available department of motor vehicles records

• Your behavior while employed by Leukemia& Lymphoma Society

You have a right to obtain a copy of any consumer report or investigative consumer report obtained by The Leukemia & Lymphoma Society by checking the box provided below. The report will be provided to you within three (3) business days after receipt of the requested reports.

Under California law (Civil Code Section 1786.22), you have the right to inspect all files maintained on you by an investigative consumer reporting agency during regular business hours and upon reasonable notice. Files may be inspected in person; copies may be requested in writing (sent certified mail); or a telephone summary of information in files will be provided (upon a written request for telephone disclosure). You may be accompanied by one other person of your choosing. The consumer reporting agency is required to provide trained personnel to explain the contents of your file and to provide a written explanation of any coded information. Proper identification will be required and you will be required to pay the actual costs of duplication services if you request a copy of your file.

At this time, The Leukemia & Lymphoma Society anticipates that any requests for inspection of non-credit reports should be directed to:

Please acknowledge that you have read and understand this Disclosure by checking the box below. Thank you.

CALIFORNIA ACKNOWLEDGEMENT: I have read and understand the above Disclosure, and I understand that the Leukemia & Lymphoma Society may not obtain a consumer report (including an investigative consumer report) without my written authorization on a separate document.*

Yes

I request to receive (CALIFORNIA ONLY)

a copy of the report prepared by checking this box

The Leukemia & Lymphoma SocietyNON-CALIFORNIA

AUTHORIZATION TO OBTAIN CONSUMER REPORT(REQUIRED FOR ALL APPLICANTS FOR EMPLOYMENT WITH THE LEUKEMIA & LYMPHOMA SOCIETY)

I acknowledge that I have read the above statement entitled "DISCLOSURE OF EMPLOYER'S INTENTION TO OBTAIN CONSUMER REPORT FOR EMPLOYMENT PURPOSES" informing me that a consumer report and/or an investigative consumer report may be requested and used for the purpose of evaluating me for hiring, current employment, promotion, reassignment, or retention as an employee.

For the employment purposes stated above, I authorize and agree that The Leukemia & Lymphoma Society may request and obtain any written, oral, or other communication of any information bearing on my creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, trustworthiness, or mode of living, from any person or any agency which assembles or evaluates individual credit information or other information on individuals for the purposes of furnishing that information to third parties. I understand that with this authorization, The Leukemia & Lymphoma Society, and/or its contracted agents may procure a consumer report on me and make an independent investigation of my background, references, character, behavior, past/present employment, military service, education, credit, motor vehicle records, criminal and police records, drug test records, civil legal records and so forth, including obtaining such records maintained by both public and private organizations and all public records.

I understand that, if requested and obtained, this information will be reviewed by The Leukemia & Lymphoma Society for employment purposes, as that term is used in the federal Fair Credit Reporting Act. I also understand that before I am denied employment based, in whole or part, on information obtained in the consumer or investigative consumer report, I will be provided a copy of the report pursuant to the Fair Credit Reporting Act. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report.

I authorize without reservation any person (including my present or past employers or other persons having personal knowledge about me) educational institutions, police departments, agencies which maintain information related to motor vehicles, government agencies, or other agencies which assemble or evaluate individual credit information or other information on individuals for the purpose of furnishing that information to third parties to provide the information described above about me to The Leukemia & Lymphoma Society or its agent. I understand that The Leukemia & Lymphoma Society may request this information from more than one such person or agency.

In exchange for The Leukemia & Lymphoma Society's consideration of my continued employment, I agree not to file or pursue any claims, rights of action, or liability of any kind or nature against any organization or individual providing the aforementioned information. I also release and discharge The Leukemia & Lymphoma Society and all its employees, representatives, officers and directors, or agents from any and all claims, rights of action, or liability of any kind or nature that arise out of or are in any way related to The Leukemia & Lymphoma Society using or relying upon a consumer report, reference check, or background investigation. I hereby agree that a photocopy of this authorization may be used and should be accepted with the same authority as the original.

NON-CALIFORNIA ACKNOWLEDGEMENT: I have read and understand the above Disclosure, and I understand that the Leukemia & Lymphoma Society may not obtain a consumer report (including an investigative consumer report) without my written authorization on a separate document.*

Yes

The Leukemia & Lymphoma Society is an Equal Opportunity Employer. Every employee has the right to work in an environment free from all forms of discrimination. We are therefore committed to a policy of equal employment opportunity. We are dedicated to providing a diverse work environment, free from discrimination and harassment and where employees are treated with respect and dignity. We recruit, employ, retain, compensate, train, promote, discipline, terminate and otherwise treat all employees and job applicants based solely on qualifications, performance and competence. All employees and applicants will be treated without regard to age, sex, color, religion, race, national origin, citizenship, veteran status, current or future military status, sexual orientation, gender identification, marital or familial status, physical or mental disability, or any other status protected by law.

You are required to enter a digital signature which will be binding as your actual signature. Your electronic signature below indicates your agreement with the following statements. By typing your name in the following box you certify the above statements to be true and correct, to the best of your knowledge, and that this information can be used for the purpose of processing your employment application and information.

I certify that the above information is true and complete to the best of my knowledge. *